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      Predicting Occluded Middle Cerebral Artery Morphology for Endovascular Mechanical Thrombectomy: A Contralateral Shape Analysis Approach

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          Abstract

          Introduction  Predicting the shape of the occluded middle cerebral artery (MCA) from the contralateral MCA might help catheterization in endovascular mechanical thrombectomy (EMT).

          Materials and Methods  We analyzed magnetic resonance (MR) angiography in 100 consecutive patients who had MR imaging for diseases other than acute ischemic stroke. To assess the symmetricity of MCA, the shape of M1, length of M1, number of M2, number of early branches (EBs), and distance from the top of the internal carotid artery to EB were investigated.

          Results  The shape of M1 was upward in 42%, horizontal in 47%, and downward in 11%. The M1 shape was the same on both sides in 64%, which exceeded the probability assumed to be left–right independent. The number of M2 trunks and EBs matched left and right in 86 and 55% of patients, respectively; however, these agreement rates were not higher than those with independent left and right sides. No left–right correlation was found between the M1 length and the distance from the internal carotid artery to EB.

          Conclusion  Based on our data, the symmetry of MCA was observed only in the shape of the M1 segment. This finding could be beneficial for EMT targeting MCA embolisms.

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          Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

          William J. Powers, Alejandro A Rabinstein, Teri Ackerson … (2019)
          Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.
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            A randomized trial of intraarterial treatment for acute ischemic stroke.

            Olvert Berkhemer, Puck Fransen, Debbie Beumer … (2015)
            In patients with acute ischemic stroke caused by a proximal intracranial arterial occlusion, intraarterial treatment is highly effective for emergency revascularization. However, proof of a beneficial effect on functional outcome is lacking. We randomly assigned eligible patients to either intraarterial treatment plus usual care or usual care alone. Eligible patients had a proximal arterial occlusion in the anterior cerebral circulation that was confirmed on vessel imaging and that could be treated intraarterially within 6 hours after symptom onset. The primary outcome was the modified Rankin scale score at 90 days; this categorical scale measures functional outcome, with scores ranging from 0 (no symptoms) to 6 (death). The treatment effect was estimated with ordinal logistic regression as a common odds ratio, adjusted for prespecified prognostic factors. The adjusted common odds ratio measured the likelihood that intraarterial treatment would lead to lower modified Rankin scores, as compared with usual care alone (shift analysis). We enrolled 500 patients at 16 medical centers in The Netherlands (233 assigned to intraarterial treatment and 267 to usual care alone). The mean age was 65 years (range, 23 to 96), and 445 patients (89.0%) were treated with intravenous alteplase before randomization. Retrievable stents were used in 190 of the 233 patients (81.5%) assigned to intraarterial treatment. The adjusted common odds ratio was 1.67 (95% confidence interval [CI], 1.21 to 2.30). There was an absolute difference of 13.5 percentage points (95% CI, 5.9 to 21.2) in the rate of functional independence (modified Rankin score, 0 to 2) in favor of the intervention (32.6% vs. 19.1%). There were no significant differences in mortality or the occurrence of symptomatic intracerebral hemorrhage. In patients with acute ischemic stroke caused by a proximal intracranial occlusion of the anterior circulation, intraarterial treatment administered within 6 hours after stroke onset was effective and safe. (Funded by the Dutch Heart Foundation and others; MR CLEAN Netherlands Trial Registry number, NTR1804, and Current Controlled Trials number, ISRCTN10888758.).
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              Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke

              Mayank Goyal, Andrew M Demchuk, Bijoy K. Menon … (2015)
              Among patients with a proximal vessel occlusion in the anterior circulation, 60 to 80% of patients die within 90 days after stroke onset or do not regain functional independence despite alteplase treatment. We evaluated rapid endovascular treatment in addition to standard care in patients with acute ischemic stroke with a small infarct core, a proximal intracranial arterial occlusion, and moderate-to-good collateral circulation. We randomly assigned participants to receive standard care (control group) or standard care plus endovascular treatment with the use of available thrombectomy devices (intervention group). Patients with a proximal intracranial occlusion in the anterior circulation were included up to 12 hours after symptom onset. Patients with a large infarct core or poor collateral circulation on computed tomography (CT) and CT angiography were excluded. Workflow times were measured against predetermined targets. The primary outcome was the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) at 90 days. A proportional odds model was used to calculate the common odds ratio as a measure of the likelihood that the intervention would lead to lower scores on the modified Rankin scale than would control care (shift analysis). The trial was stopped early because of efficacy. At 22 centers worldwide, 316 participants were enrolled, of whom 238 received intravenous alteplase (120 in the intervention group and 118 in the control group). In the intervention group, the median time from study CT of the head to first reperfusion was 84 minutes. The rate of functional independence (90-day modified Rankin score of 0 to 2) was increased with the intervention (53.0%, vs. 29.3% in the control group; P<0.001). The primary outcome favored the intervention (common odds ratio, 2.6; 95% confidence interval, 1.7 to 3.8; P<0.001), and the intervention was associated with reduced mortality (10.4%, vs. 19.0% in the control group; P=0.04). Symptomatic intracerebral hemorrhage occurred in 3.6% of participants in intervention group and 2.7% of participants in control group (P=0.75). Among patients with acute ischemic stroke with a proximal vessel occlusion, a small infarct core, and moderate-to-good collateral circulation, rapid endovascular treatment improved functional outcomes and reduced mortality. (Funded by Covidien and others; ESCAPE ClinicalTrials.gov number, NCT01778335.).
              Article 0 comments Cited 995 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Asian J Neurosurg
                Journal ID (iso-abbrev): Asian J Neurosurg
                Journal ID (doi): 10.1055/s-00053244
                Title: Asian Journal of Neurosurgery
                Publisher: Thieme Medical and Scientific Publishers Pvt. Ltd. (A-12, 2nd Floor, Sector 2, Noida-201301 UP, India )
                ISSN (Print): 1793-5482
                ISSN (Electronic): 2248-9614
                Publication date (Electronic): 24 June 2024
                Publication date Collection: September 2024
                Publication date PMC-release: 1 June 2024
                Volume: 19
                Issue: 3
                Pages: 435-438
                Affiliations
                [1 ]Department of Neurosurgery, Medical Corporation Shokokai San-ai Hospital, Saitama, Japan
                [2 ]Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
                [3 ]Department of Neurosurgery, Teikyo University School of Medicine, Tokyo, Japan
                [4 ]Department of Neurosurgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
                Author notes
                Address for correspondence Soichi Oya, MD, PhD Department of Neurosurgery, Saitama Medical Center 1981 Kamoda, Kawagoe, Saitama 350-8550Japan sooya-tky@ 123456umin.ac.jp
                Author information
                http://orcid.org/0000-0002-0842-5092
                Article
                Publisher ID: AJNS-24-3-0010
                DOI: 10.1055/s-0044-1787869
                PMC ID: 11349394
                SO-VID: 72c4a5ae-4878-4325-aab3-ddcde0ebbd6f
                Copyright © Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ )
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License, which permits unrestricted reproduction and distribution, for non-commercial purposes only; and use and reproduction, but not distribution, of adapted material for non-commercial purposes only, provided the original work is properly cited.

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                Subject: Original Article

                ScienceOpen disciplines: Surgery
                Keywords: cerebral embolism,endovascular mechanical thrombectomy,middle cerebral artery,mr angiography,symmetry
                Data availability:
                ScienceOpen disciplines: Surgery
                Keywords: cerebral embolism, endovascular mechanical thrombectomy, middle cerebral artery, mr angiography, symmetry

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